Surgical Pathology Specialty Sign Outs

[Mrbojangles]

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What do you think of specialty sign outs for surgical pathology? I have to admit that I don't know much about it. I probably will go into community practice so it wont mimic general surgical pathology in the community hospital. And can you learn pathology (a field that is so vast) systematically going by organ systems? 😕

 

[yaah]

I know the argument of some against subspecialty signout is that you will keep seeing things in the same area over and over, you won't have "the variety" and such. I don't really buy it. It's not like, if there is a general surg path signout, that you keep getting unknowns and you somehow get better at distinguishing certain cases. You still see the same specimens, it is just more focused - I almost think it's easier to study and stay on top of things.

They just switched to a modified form of subspecialty signout here - we do all GI, all GU, all GYN, or the rest all together. And it can be more grueling. Surgeons tend to batch cases together, so certain days are more traditionally GI specimen heavy, lung case heavy, whatever. If you are on a general rotation that might not matter as much. But if you have to do all the GI specimens and a higher proportion that day are GI, well you're stuck.

I don't think it hurts you at all in preparing for community practice - like I said you will still see everything, and it permits you to focus on a certain area and learn it in more detail. Sometimes if you are doing general surg path and you get a lung, then a prostate, and then a colon, you might not learn as much as if you see three consecutive prostates with different tumors.

You start at 5am? For previewing, I assume?

Once I do more surg path here I will let you know how it goes - so far after the switch to subspecialty it is working pretty well.

 

[desmangt]

I know the argument of some against subspecialty signout is that you will keep seeing things in the same area over and over, you won't have "the variety" and such. I don't really buy it. It's not like, if there is a general surg path signout, that you keep getting unknowns and you somehow get better at distinguishing certain cases. You still see the same specimens, it is just more focused - I almost think it's easier to study and stay on top of things.

They just switched to a modified form of subspecialty signout here - we do all GI, all GU, all GYN, or the rest all together. And it can be more grueling. Surgeons tend to batch cases together, so certain days are more traditionally GI specimen heavy, lung case heavy, whatever. If you are on a general rotation that might not matter as much. But if you have to do all the GI specimens and a higher proportion that day are GI, well you're stuck.

I don't think it hurts you at all in preparing for community practice - like I said you will still see everything, and it permits you to focus on a certain area and learn it in more detail. Sometimes if you are doing general surg path and you get a lung, then a prostate, and then a colon, you might not learn as much as if you see three consecutive prostates with different tumors.

You start at 5am? For previewing, I assume?

Once I do more surg path here I will let you know how it goes - so far after the switch to subspecialty it is working pretty well.

Not all specialty signout is looking at a specific organ system per day. Yale does specialty sign out is blocks. You do a month of GYN, then a month of GU, etc. The thing I didn't like about this was that after that month you won't see a prostate again, etc. In NYC, Mt. Sinai and Columbia have specialty sign out. Columbia has specialists for alot of organ systems but not everything. You gross the specimens that are assigned to you, then you go to the specialty pathologists that matches that organ and sign it out. Mt. Sinai has the same thing, but more specialized. For example, if you get a liver, colon, and prostate all in one day, you gross them in, then sign them out with the specific pathologists that cover those organ systems. I think it is an amazing opportunity because you get lots of diversity in a day's time and you get better teaching since they are truly experts in what they are signing out.

 

[yaah]

I didn't mean to imply that each day was a different subspecialty - the rotations are by month here too. It's just that some days you will be busier than others if the OR is GI heavy, for example, whereas if you were grossing whatever came in that might not be an issue.

The system at Mt Sinai sounds good on the surface, but it would also have to be coordinated fabulously well. If you have specimens from 3-4 different subspecialties that means you have to coordinate with 3-4 different attendings on what time you want to sign out. That, to me, means that they will probably all want to sign out at the same time and it could cause problems, like, "well, leave it with me and we'll go over it at another time." Plus, signouts are very rarely able to be timed accurately - thus allotting 1 hour for your prostate cases and scheduling your colon cases for immediately after might be a problem. I visited a couple of places that were doing things like this and these were the problems I thought might arise - in talking to some residents it did seem like it often did happen like this. If the program has it worked out well, perhaps it can work though.

My ideal for subspecialty signout though is a resident assigned to a specific subspecialty for weeks at a time, seeing only cases in that system. You are right, the drawback is that you don't see things in that area at other times. But conferences and slide sessions can help even that out a bit.

 

[cytoborg]

I love specialty signout! Seeing the same things over and over, and seeing things related to each other, really helps pound it into my head, and allows for more in-depth reading and learning. I don't know if one day at a time would really give me the chance to develop a feeling of semi-competency, but a week or a month at a time is grrrrreat.

 

[Mrbojangles]

Seems like there would be alot of wasted time coordinating sign outs with multiple attendings if you get assigned random cases.

I have to admit that specialty sign outs would allow for more in depth learning about a particular organ system if one has the responsibility over all the cases for that system for a few weeks. And it would probably reinforce what you read better. However there's something weird (to me at least) about not seeing a case from a different organ system for months especially if surgical pathology is spread out. And I still feel that seeing a wide variety of cases every day is more helpful for the regular community pathologist. I think the best approach for me to being well rounded would be to tackle something whole and making many mistakes and learning forgotten material many times.

I'm from a school that has a smaller pathology program so there aren't enough faculty to be the GI guy or the Lung guy. In these bigger programs with specialty sign outs do the attendings only sign out cases within their specialty. Do they rotate between specialties?

 

[desmangt]

Seems like there would be alot of wasted time coordinating sign outs with multiple attendings if you get assigned random cases.

I have to admit that specialty sign outs would allow for more in depth learning about a particular organ system if one has the responsibility over all the cases for that system for a few weeks. And it would probably reinforce what you read better. However there's something weird (to me at least) about not seeing a case from a different organ system for months especially if surgical pathology is spread out. And I still feel that seeing a wide variety of cases every day is more helpful for the regular community pathologist. I think the best approach for me to being well rounded would be to tackle something whole and making many mistakes and learning forgotten material many times.

I'm from a school that has a smaller pathology program so there aren't enough faculty to be the GI guy or the Lung guy. In these bigger programs with specialty sign outs do the attendings only sign out cases within their specialty. Do they rotate between specialties?

At Columbia and Mt. Sinai, you are assigned an attending pathologist when on surgical path that will sign out most things with you. But if a difficult case comes up or you want more detailed training, you have the option to take it to the specialist who has a list of what specimens in his division are going to be signed out that day. So, the specialists know how many specimens that need to be signed out that day and they will accomadate their schedules to get the work done. Its a pretty solid system, but I do agree that is requires alot of organization and that alot of responsibility falls on the shoulders of the resident. I think it is pretty high yield learning, but everyone has their own taste on how to do things. Cornell, NYU, and Einstein mostly have general surgical pathologists.

 

[yaah]

I'm from a school that has a smaller pathology program so there aren't enough faculty to be the GI guy or the Lung guy. In these bigger programs with specialty sign outs do the attendings only sign out cases within their specialty. Do they rotate between specialties?

Attendings will stay within their own specialty for certain areas. Like, the volume of GYN path is generally big enough so that attendings at large institutions can only signout GYN path. However, for things like lung, soft tissue, generally different attendings will rotate through the service. There still is a "lung guy" but the lung guy also will sign out the other stuff, and maybe take some time on the GI or GYN service too, if that is an area they are comfortable in.

The places with the biggest volume are really the only ones where the attendings are strictly specializing. In general, someone who is a GI pathologist will also spend time on the general service.

So, to answer your question, yes, sometimes they rotate. But for some specialties they don't. And there is a lot of interinstitutional variability.

Dr Kurman from JHU who was here today as a visiting professor said he has only looked at GYN path for the last 10-15 years. Then again, he is also one of the top 5 GYN pathologists in the world.

 

[Mrbojangles]

Interesting stuff guys. I think I should be more open minded toward the specialty sign out approach or I should put a big X on alot of programs.

 

[governaitor]

Specialty sign out is great, but I wouldn't base my decision on where to go only on that, in fact I wouldn't base it on that at all. Just know that no matter how surg path is organized wherever you go, you can have a quality experience.

 

[Doctor B.]

We do general sign out but there is talk of going to subspecialty sign out in the future. As a staff, I think it would be great if you have one area you love and could devote all your time to becoming excellent at it. On the other hand, it's nice to see some other things besides just gyn, prostate, whatever.

As a resident, as has been said above, I think I'd learn a certain topic much better if I saw just that type of case for several days in a row. The down side, again as someone said above, is that you may not see that topic for a while once you finish your rotation in it.

I'm not sure if there's a good solution. General sign out is more like private practice and will get you in the mindset of having to switch gears with each case. Specialty sign out is better for learning one topic well. I don't think either system is bad and I wouldn't necessarily exclude a program based on either method. You will work with what you have and learn the material either way.

 

[b&ierstiefel]

I'm not sure if there's a good solution. General sign out is more like private practice and will get you in the mindset of having to switch gears with each case. Specialty sign out is better for learning one topic well. I don't think either system is bad and I wouldn't necessarily exclude a program based on either method. You will work with what you have and learn the material either way.

I can't agree with you more. As an applicant, I thought this was going to be an important issue; however, I don't know what to think now that I've thought about and heard some of the pros and cons to either system. I figure we can all adapt to whatever program we match into.

I know Michigan just changed from general to specialty signout a month or two ago. That's when I was first introduced to the whole notion of general vs. specialty signout. I thought it was kind of a cool idea. I'm really curious to see how it's working and if the residents are overall happy with this change. Or maybe it's too early to tell since there are probably some little logistical kinks that need to be ironed out.

 

[Mindy]

Governaitor: I bet you are an MGH'er. I don't think there are many other places you see whipples 2-3x per week.

Mindy

 

[Mrbojangles]

Governaitor: I bet you are an MGH'er. I don't think there are many other places you see whipples 2-3x per week.

Mindy

Hey Mindy,
I think I remember you answering one of my questions about pathology a few years ago. I'm a fellow Upstater applying for path residency programs now. How do you like your program? Did you feel your elective experiences prepared you well for residency? Do you have any opinions on specialty sign outs?
John

 

[Doctor B.]

Governaitor: I bet you are an MGH'er. I don't think there are many other places you see whipples 2-3x per week.

Mindy

Actually, at IU, we see about that many (somtimes more) believe it or not. It's crazy. I never thought a Whipple would become a "routine" specimen.

 

[b&ierstiefel]

Specialty sign out is great, but I wouldn't base my decision on where to go only on that, in fact I wouldn't base it on that at all. Just know that no matter how surg path is organized wherever you go, you can have a quality experience.

You know, on second thought, I think I would prefer subspecialty signout. I understand that some people prefer variety during a sitting at the microscope and others prefer to stick to one theme. Personally, general signout is reminisccent of my family medicine rotation. I really didn't like the variety thing as it threw off my thinking every 15 minutes...patient #1 with ass cancer, patient #2 with bunion (although attending hypes it up by saying it could be gout), patient #3 is a 2 ppd smoker with chronic bronchitis, patient #4 has a skin tag, patient #5 needs a refill on his viagra, etc etc etc.

 

[yaah]

My theory is that they both have the potential to be good - it depends on things like teaching, responsibilities, organization, etc. A subspecialty signout can leave part of your education lacking if one of the subspecialties doesn't provide adequate teaching (some attendings simply don't like teaching, despite working at a teaching hospital). So, it runs the risk of saturating you with too much GI and GU while never seeing things like pediatrics.

I am at the VA now, which doesn't have enough volume to be subspecialized, one attending signs out everything each day. I enjoy it, lots of variety. Even in subspecialty signout you are unlikely to see lots of certain types of specimens. You may see lots of GI polyps and cancers, but on a general service you will often see this too.

So I think the question people should be asking at interviews is how signout is integrated into resident education, and how variety is handled, etc.

 

[Mrbojangles]

I think I'm coming around to being neutral to the idea of subspecialty signout in surgical pathology. I agree that you'd probably learn each organ system better if you can just focus your reading on that system for a month or two and just see similar cases one after the other. It's just like medical school for curriculums that block by organ systems. I'd probably like to have experience with a general surgical pathology signout whether at a VA or an away elective though towards the end of my residency.

 

[yaah]

Bump for the poster in the other thread